1. Since I was able to feel a lump in my breast, why
didn't it show up on the mammogram?

The most likely explanation for this occurrence is that the
tumor was hidden in the middle of glandular tissue.
Another explanation is that the mammographer did not see it because
it was very small or subtle. Another possibility is that some
cancers do not form lumps which would show up as a spot on the
mammogram. Infiltrative cancers are more spread out. Many,
many cells are spread out over an area and are not visible on
mammogram. Another explanation is that some tumors are confined to
the skin of the nipple and won't show up on mammogram.

2. What is a microcalcification?

Calcification represents precipitated calcium salts from the
blood that leach out in areas in which there is necrotic (dead)
tissue. The calcium then literally, precipitates out in the dead
tissue. Other calcifications are calcium salts that are picked up
by certain secretions made by cancers.

3. What causes benign calcifications?

They are produced by secretions of the duct system of the
breast- rarely by necrosis(waste product of dead cells). The breast
normally secretes all the time, even when the woman is not
lactating or pregnant and even if she's never been pregnant or
never breast fed. Some of the proteins are like milk proteins but
it's not milk. But some of these proteins, as they become denatured
(decomposed) in a duct, will pick up calcium salts -- will leach
out calcium salts from the blood and these are called
calcifications.

4. What is a core biopsy ?

The core biopsy is a procedure that takes a sample of your
breast lump. It uses a tiny cylinder (the width of an 11-18 gauge
needle- about the sized used when you donate blood) to withdraw
biopsy material. In 1989 a powerful spring was added to the coring
needle. This produces a biopsy that is much more efficient and
obtains a much better specimen than a Fine Needle
Aspiration (FNA). The FNA is mostly used now to distinguish
cysts (fluid containing lumps) from solid lumps but not for
diagnosing cancer.

5. What is a Mammotome?

The Mammotome is a new instrument for breast biopsy that was
approved by the FDA in 1995. It is a mini scalpel
(surgical knife blade) that is within the core biopsy equipment.
The Mammotome has a very sharp blade on its edge that whirrs
around. The desired specimen is then suctioned out by a vacuum
system. The advantage of the Mammotone over the traditional
core biopsy is that the Mammotome can obtain bigger
samples. The Mammotome biopsy is also performed faster and with
only one needle insertion which aids in the comfort of the
patient.

6. What is a stereotactic biopsy?

Stereotactic is a general medical term that means
using multiple images to direct a mechanical arm. Thus a
core biopsy as well as a Mammotome would be considered
stereotactic because they are both directed by multiple
images of the breast.

7. What is a needle localization (needle
loc)?

A needle localization is used when there is not a palpable
(feelable) lump. A fine needle is inserted into the breast,
directed by the mammogram where the questionable area is visible.
The surgeon then knows which area needs to be removed. Needle
localization serves as a marker for the surgeon. This technique is
used for both biopsy and removal.

For invasive breast cancer a clean
(cancer-free) margin of two or three millimeters is
sufficient. In DCIS (Duct Carcinoma In Situ) it needs to be larger
depending upon the type of DCIS. Generally, we recommend clear
margins of 10 millimeters (one centimeter) although that's
difficult to achieve. (See section on DCIS for further
explanation).

2. After lumpectomy if the margins still have cancer
cells in them would I then need a mastectomy?

No, a re-excision will often be sufficient to obtain clear
margins.

3. If it's been re-excised, and the margins are still
not clear will I then need a mastectomy?

Not necessarily. For invasive breast cancer, radiation therapy
may be sufficient especially if the tumor is low grade and the
margins are small but not transected (cut through). In this case
very close follow up is mandatory in order to detect a recurrence
at a very early stage. Also, in a woman with a larger breast,
enough breast tissue may be available to perform a second
re-excision and still have an acceptable cosmetic outcome.
In DCIS, if the margins are not adequate, radiation therapy may be
considered depending upon the margin size and grade of the tumor.
As with invasive cancer, in a woman with a larger breast, a second
re-excision may be done for DCIS. There are times, however, when
mastectomy may be needed for the best local control.

4. Why do I need a lymph node sampling?

A lymph node sampling (or dissection) assesses the
potential of the cancer to recur systemically (spreading throughout
the body) and advises doctors on further treatment needed after
surgery (such as chemotherapy). Lymph nodes are removed from the
axilla which means armpit, thus the term
Axillary Lymph Node Dissection

5. How many nodes will be sampled
(removed)?

Each patient is different. An area of fatty tissue under the
armpit is removed. This pad of tissue contains varying numbers of
nodes in each patient- generally 5-20. It is not known how many
nodes are removed until the pathologist dissects the pad of tissues
in the laboratory. There are a total of three levels of axillary
lymph nodes. Level one nodes refer to nodes below the pectoralis
minor muscle. These are the nodes closest to the breast. In a
traditional Lymph Node Dissection, level 1 and 2 are removed. Level
three nodes are rarely removed in the United States.

6. What is a Sentinel Node or Blue
Node procedure?

This is a new procedure that may replace lymph node removal in
patients who have a low risk of having any positive
(cancer-bearing) lymph nodes. A radioactive or blue dye is injected
around the tumor (or tumor site if the tumor has already been
removed for biopsy). The dye is traced to the first node
(sentinel node) closest to the tumor site, that node is
removed and examined for signs of cancer cells. If the
sentinel node is free of cancer cells it is very likely
that the rest of the nodes are also free of cancer. Therefore the
patient may not need a traditional lymph node removal.

7. How long do I need to stay in the hospital for my
lymph node dissection?

If only sentinel node dissection occurs, then you can leave the
hospital the same day of surgery. For other lymph node dissection
procedures an overnight stay is generally recommended.

8. What are the short term and long term side effects
of lymph node dissection?

Short term side effects include soreness, stiffness and seroma.
A seroma is a mass caused by the localized accumulation of serum,
or clear fluid, within a tissue or organ. Long term side effects
include lymphedema and numbness under the arm. Lymphedema is an
accumulation of fluid that may collect in the arm when lymph
vessels are removed. This can cause the arm to swell and become
disfigured and painful.

9. What is the risk of lymphedema and how can I prevent
it?

The risk of lymphedema is about 3-5%. We will give you an
information sheet that describes 18 steps that can be taken to
prevent lymphedema.

10. Isn't mastectomy the most secure treatment for
breast cancer or DCIS?

Generally mastectomy and lumpectomy with radiation are equally
effective in terms of long-term survival. Women who have lumpectomy
(with radiation) will need careful follow-up to detect local
recurrence in the breast. But even if the woman has a recurrence
her survival rate is the same as the woman who had a mastectomy.
(See General Questions About Breast Cancer)

11. Are there any advantages offered by a breast
surgeon vs. a general surgeon? How do I know if someone is a breast
surgeon?

Breast surgeons are generally more up-to-date on the current
literature and techniques used in breast cancer treatment. Ask the
surgeon how much of his or her practice is devoted to the breast.
Also ask the physician if she or he does a lot of close follow-up
on patients at high risk (as opposed to a physician who just
performs surgery).

12. Would multi-stage surgeries contribute to the
spread of cancer?

No. Neither do needle biopsies. Multi-stage refers to
the practice of performing one surgery at a time, for example,
first the biopsy would be performed and then the mastectomy or
lumpectomy would be performed at another time. Multi-stage
surgeries can sometimes lead to more information and better
decision making.

In almost all cases, the answer is yes. Immediate
reconstruction will usually provide the best
aesthetic and psychological outcome. The reasons why immediate
reconstruction is generally preferable are:a. It is possible to save more skin when
immediate reconstruction is done. A more natural breast can be
reconstructed, especially with the TRAM Flap procedure.b. Because more skin is saved with immediate
reconstruction, more of the skin sensation of the breast can be
preserved. (Nipple sensation will be lost in any event because the
nipple must be removed.) A new nipple and areola, without
sensation, can later be created.However, in the following circumstances immediate
reconstruction is not possible or advisable:a. The tumor is very large and has invaded areas
beyond the breastb. It was not possible for the surgeon to remove
the entire tumorc. A woman or her physician may prefer that
chemotherapy be administered before breast reconstruction. Some
physicians feel that healing of the reconstruction may be
compromised by the immunosuppressive effects of chemotherapy.

2. What is the TRAM Flap procedure?

TRAM means Transverse Rectus Abdominus Myocutaneous Flap.
In simple terms:Transverse - because the abdominal skin and
fat used in the reconstruction is removed in a side-to-side
fashion.Rectus Abdominus - refers to the muscle/s that
must be taken with the skin and fat to nourish the tissue.Myocutaneous - means both muscle and skin are
utilized. This is a type of reconstructive surgery of the
breast following mastectomy, uses skin and fat from the
belly left attached to abdominal muscle/s. The
skin/fat tissue must remain attached to its
original site, to retain its blood supply. The entire
flap, consisting of the skin, fat, and muscle, is tunneled
underneath the abdominal skin to the
chest, creating the newly reconstructed breast. Later, a
new nipple is made with skin on the chest, and an areola is
tattooed around the nipple. This creates a very natural-looking
breast. Complete recovery from the surgery takes about six weeks.
Flap surgery is more complex than implant surgery.

3. What are the side effects of removing abdominal
muscle in the TRAM Flap procedure?

Since your rectus abdominis muscle(s) are removed, you may
no longer be able to do conventional sit-ups. However, since the
abdominal wall contains many other muscles and you have
only lost 1 or 2, the other muscles can be
retrained to take over some of the function of the rectus
abdominis. It is important to keep the remaining abdominal muscles
strong in order to avoid future back problems.

4. How much muscle is removed?

The entire rectus abdominis is used to reconstruct one
breast. Sometimes both rectus muscles are needed, even to
reconstruct one breast. In the case of a double mastectomy
both muscles must be used to create two
breasts.

5. Why does the surgeon need to use the muscle? Why
can't he or she just use the fat?

The muscle contains the arteries and veins which provide life
sustaining blood to the skin and fat.

6. Will a TRAM flap affect athletics or my ability to
walk?

It will not affect your ability to walk. If you are very athletic
you should discuss the procedure with your surgeon.

7. What is a "free-flap"?

The "free-flap" is a technique which actually detaches
tissue from one part of the body with the arteries and veins
intact and transplants it to the chest. Microsurgical
techniques are then used to suture the blood vessels to vessels on
the chest to provide blood. This procedure requires the skills
of a plastic surgeon who is experienced in microvascular
surgery.

8. What about breast implants?

A simpler operation for breast reconstruction is to use tissue
expanders and breast implants placed under the chest muscles.
Tissue expanders are special implants that can be inflated over a
period of several weeks to several months by painlessly injecting
them with saline. Over a period of time they slowly fill,
increasing in size. Once they get to the appropriate size, they are
exchanged for regular, permanent breast implants.

9. How will I be monitored for recurrence if I have
reconstruction?

You should have a clinical breast exam every six months to check
for local recurrence. You should have one mammogram several months
after your TRAM flap reconstruction to check for fat necrosis (dead
tissue). After that there is no need for a mammogram in the
reconstructed breast. A recurrence would be extremely rare.
However, your other breast should still be checked by mammogram on
a regular basis. The frequency will depend on your diagnosis.

10. Is reconstruction possible to do after radiation?
For example, if I have a recurrence several years after I was
treated with lumpectomy and radiation, can I have a mastectomy with
reconstruction?

You can successfully have a flap procedure (such as a TRAM
Flap) after radiation. Breast implants may have a
higher rate of complications following radiation because
of microscopic damage to the blood vessels of the skin.

1. Now that I have breast cancer or DCIS how often do I
need a mammogram?

For DCIS, you should have a mammogram every 6 months for two
years, after that a mammogram should de done yearly. For invasive
cancer, if you had a lumpectomy have a mammogram every six months
for two years, then yearly. If you had a mastectomy have a
mammogram once a year.

2. Now that I have breast cancer or DCIS how often do I
need a clinical breast exam ?

Your breast surgeon and radiation oncologist should examine your
breasts every three months for two years then every 6 months
indefinitely.

3. How often should I do breast self
-exam?

Once a month. Breast self-exams should be done 5-7 days after your
period starts. For postmenopausal women, pick the same day of every
month for your breast self-exam.

4. What about ultrasound and MRI?

These tests are indicated on an individual basis. You may be
eligible for a clinical trial that uses MRI for follow-up. Ask us
for additional information.

5. Should I have a bone or liver scan?

This depends on your stage of cancer. Make this decision with your
physician or team.

1. What is the difference between the recurrence rate
and the survival rate?

Survival rate refers to how long the patient will live and does
not take into consideration whether or not the patient has
recurrences. The recurrence rate represents recurrences in the
breast, as well as metastases (spread of the cancer from original
site to a distant site) elsewhere in the body. There are two
aspects of breast cancer; the local control and the distant
metastases. A recurrence in the breast, generally does not affect
survival. On the other hand, when we use the term
recurrence to mean metastatic events -- we're talking
about disease that's outside of the confines of the breast. This
may effect survival time.

2. Is the recurrence rate lower if the patient has a
mastectomy?

The local recurrence rate would be lower but survival time would
be the same. Very rarely a recurrence will occur in the tiny amount
of breast tissue that remains after a mastectomy. Many women are
concerned about the possibility of recurrence and spread of the
cancer if they don't have a mastectomy. In theory, it is more
dangerous to keep the breast because a recurrence has the potential
to spread and become metastatic, but in reality statistics show
that with good follow-up, the recurrences are caught at an early
stage and survival is not affected. This has been born out in
research studies comparing large numbers of women who have either
mastectomy or lumpectomy and radiation- the survival rates are the
same. Radiation is also very effective in destroying any leftover
cancer cells that may remain in the breast. It is so effective that
some researchers are starting to recommend that women have
radiation even if they have a mastectomy, especially if their tumor
was large or aggressive. Currently, radiation after mastectomy is
only used when there is a very high likelihood of residual disease
in the breast, in the chest wall, or very high risk for
recurrence.

3. Why does the cancer sometimes spread to the chest
wall after a mastectomy?

When you remove the breast, metastases tend to go to areas where
the blood vessels are abnormal. After a mastectomy, scar tissue
remains, and the cancer is more likely to go into this scar tissue.
Many women who have a recurrence in the chest wall after
mastectomy, in short order, develop recurrences or metastases
elsewhere. So, it's a signal that there is high potential for
metastatic disease. Recurrence in the chest wall has a much heavier
significance in terms of survival. Whereas, the local, in-
the-breast recurrence does not jeopardize survival.

4. How can I tell if my cancer has spread beyond my
breast or beyond my lymph nodes, if my lymph nodes are
positive?

Its important to know that breast cancer doesn't always spread
directly to the lymph nodes. It can travel beyond the breast
directly through the blood stream and lymph system even if the
lymph nodes are negative. That is why in some cases, especially
with large or aggressive tumors, it is necessary to use
chemotherapy even if no lymph nodes are affected. CT scans and bone
scans should be done if your physician feels that there may be a
chance of metastasis.

1. What are the chances of my DCIS turning into
invasive cancer without any treatment?

That depends on the grade, size, and margin status of the DCIS
(Ductal Carcinoma In Situ). Time is also an important factor. The
rates of DCIS becoming invasive are different at 5 years, 10 years,
or 15 years. This is an excellent question to ask the BCCS panel
about your specific situation.

2. What are the recurrence rates after a
lumpectomy?

The recurrence rates after a lumpectomy depend on the grade, size,
and width of the narrowest margin. This is a good question to ask
the panel about your specific diagnosis.

3. Is radiation therapy an effective treatment for
DCIS?

Usually not. Evidence suggests that it is not of benefit in
low-grade DCIS and has little impact on high-grade lesions.
Radiation therapy does have a modest benefit for intermediate grade
lesions where the margins are absolutely clear. The benefit in that
group is small- about 14% at 7 years of follow-up. However, the
benefit of radiation therapy only lasts a relatively short period
of time. There's a great deal of benefit for the first 5 years.
But, between 5 and 10 years, the benefit wears off. During the next
5 years it rises rapidly and at 10 years, the results starts to
approach those of lumpectomy alone. Radiation works better on
highly active metabolic tissue such as invasive cancer.

4. How long does it take DCIS to develop?

Some forms of DCIS are present for years in the breast without
changing. Some forms of DCIS are associated with subsequent
invasive growth after 4 to 8 years. There are instances in which
there is a small area of microcalcification, which had been thought
to be benign and was followed for 5 or 6 years. And then, all of a
sudden, something changes. Little spiculations grow out of it.
Spiculations are markings with little spikes on them.
These indicate the presence of the cancer. So, we can document, in
retrospect, that this cancer was present as an in situ cancer for 5
or 6 years, and then invasive cancer developed from it.

5. How long would it take DCIS to show up on my
mammogram as microcalcifications?

No one knows that. We do know that, on the basis of the appearance
of microcalcifications, that sometimes DCIS can appear to grow very
rapidly. We don't know if they're really growing rapidly or that
simply more of the lesion is showing calcification -- because the
calcification doesn't always occur in every in situ cancer.
Sometimes, the calcification may mark only a portion of the tumor.
Sometimes, it doesn't mark any of it, even when necrosis (cell
degeneration) is present.

6. Is it true that DCIS will not always be detected by
a mammogram?

Yes, if the DCIS is not marked by microcalcifications it will not
show up.

7. Why do you need such large surgical margins for
DCIS?

With invasive cancer, if we remove most of it but there's a little
bit left, radiation generally can destroy that. But with DCIS,
you're not destroying the cancer completely and its generally
resistant to radiation therapy. In many cases, you don't touch it
and so its important to have larger margins around the DCIS
areas..

8. Is it safer to have a mastectomy for my
DCIS?

The difference in survival between breast conservation for DCIS
and mastectomy for DCIS is 1% after 15 years of follow-up -- 1%
survival advantage for patients who have mastectomy. So, there's
not a lot of incentive to choose a mastectomy.

9. Is age a factor in recurrence?

Yes, particularly in women under 40 years of age, in both DCIS and
invasive cancer, younger women have a higher recurrence rate.

Radiation is usually done after the tumor is removed by
lumpectomy. Radiation is done to prevent spread of tumor cells in
the breast that may have been left over and to prevent local (in
the breast), recurrence of cancer. Radiation is also done after a
mastectomy if there is a high risk for chest wall cancer. Recent
studies may indicate that there may be some benefit to routine
administration of radiation to the chest wall after mastectomy.

2. What are the short term side effects of radiation
therapy?

The short term side effects of radiation therapy are a
sunburn-like reaction in the area that was irradiated. The
irradiated area may be pink, irritated, or itchy. There may be
moist desquamation in a small area under the arm and under
the breast. Moist desquamation is a condition whereby the
skin sheds and becomes moist because the area under the arm and
breast is moisture-producing. These side effects will occur in the
third week of radiation and will last for the duration of
treatment. Constitutional side effects include mild appetite
suppression, and mild fatigue, usually occurring in the 2nd or 3rd
week and lasting until the end of treatment or possibly a few weeks
or months beyond in some patients. Most patients are able to
continue to work while being treated. Approximately 1-3% of
patients may get radiation pneumonitis which is an
inflammation of the lining of the lungs. It is successfully treated
with steroids such as cortisone. If the lymph nodes are not
irradiated there is less chance of pneumonitis. 1-3% of patients
will get spontaneous fracture of the rib in areas that have been
irradiated. This may not be felt at all but will show up on
xray.

3. What are the long term side effects of radiation
therapy?

A long-term side effect is radiation fibrosis which is a
scarring of the lung caused by a small part of the lung being
irradiated during treatment. It usually does not cause symptoms but
rarely it may cause shortness of breath or cough. Almost all
patients will get some minimal degree of radiation
fibrosis seen on xray, but only 1-3% will have symptoms.

4. Can radiation cause cancer later in my
life?

Even more rare than the above side effects is the chance of
developing a secondary malignancy. Approximately 1% of patients
will develop a soft tissue sarcoma (a form of cancer). This may
develop 10-20 years after treatment. The first signs would be skin
changes usually at the site of the previous radiation. Report any
skin changes or masses to your radiation oncologist who will be
following you closely after your treatment. We want to emphasize
that a secondary cancer is extremely rare and that the benefits of
radiation therapy far outweigh the very small potential for
secondary cancers.

5. Will my hair fall out as a result of radiation
therapy?

The hair on your head will not fall out, but you may lose some
hair under your arm.

6. How long does treatment last?

The treatment is given five days per week for 7 weeks. During the
first 5 weeks the entire breast is irradiated. During the last two
weeks the lumpectomy site alone is given a booster dose.

7. What is the usual dose ?

The usual dose is 4,500-5,000 rads. The usual dose to the booster
site is 1500-2,000 rads. The total dose of treatment is 6500
rads.

8. How long after radiation should I wait to get
pregnant?

At least one year.

9. How long a period after diagnosis with breast cancer
can I safely wait before beginning radiation
treatment?

It's important to begin radiation therapy within 4 months of
diagnosis. After that the effectiveness of radiation treatment may
decline.

In general, patients receive chemotherapy if they have positive
lymph nodes or large and or aggressive invasive tumors. However,
recently there is a general trend toward treating women with
chemotherapy who have smaller and less aggressive tumors. This is
because studies are showing better outcomes when chemotherapy is
included in the treatment plan. For example, in previous years
patients would be given chemotherapy if their tumor size was
greater than 3 centimeters ( a centimeter is about ½ inch.).
But now studies are showing that there may be some benefit to using
chemotherapy if the tumor is 1 centimeter or greater if the tumor
is aggressive or shows negative characteristics such as a poorly
differentiated tumor, high S phase, HER2/neu positive, or hormone
receptor negative (estrogen and/or progesterone). (Please see our
patient information sheet called Breast Cancer Terminology for
definitions of the previous terms). Also, patients with local
advanced disease (growth of the cancer into the chest wall, for
example) definitely need chemotherapy. Finally, chemotherapy is
indicated in women with metastatic disease- particularly either
lung or liver metastases, or in women who are showing signs of
progressive disease. Whether or not to use chemotherapy is a highly
individual decision and an important reason for obtaining a second
opinion from a medical oncologist or panel that includes medical
oncologists.

2. When is chemotherapy administered?

If the tumor is relatively small, a lumpectomy or mastectomy is
performed first followed by chemotherapy. In many cases, the biopsy
that originally diagnosed the cancer, also served as
lumpectomy to remove the cancer. If the surgical margins
surrounding the tumor were adequate, that is free of cancer, then a
patient can procede to chemotherapy. If the margins are too small
or transected (cut through), then a re-excision may be needed
before chemotherapy is administered. (Please see section on
Surgery). Sometimes chemotherapy is administered before surgery in
order to shrink a large tumor. This is called neo-adjuvant
chemotherapy. This may make it possible for a woman to have a
lumpectomy rather than a mastectomy. Some patients (usually stage
III patients who's tumors are 5 cm or larger) are given the
sandwich method. First chemotherapy is given, for two to
three cycles followed by surgery. Then three cycles of chemotherapy
and finally radiation therapy. Then an additional course of
chemotherapy is given.

3. What types of chemotherapy are available for breast
cancer?

There are various single agents and combinations of drugs that
work against breast cancer cells. The most commonly used drugs are:
Cytoxan (cyclophosphamide), Methotrexate, 5 fluorouracil (5 Fu),
Adriamycin (doxorubicin), Taxol (paclitaxel) and Taxotere
(docetaxel). Frequently used combinations are:AC - Adriamycin, CytoxanCMF - Cytoxan, Methotrexate, 5 fluorouracil
More recently, the taxanes - Taxol, or Taxotere, are
being used especially when a patient has a large number of positve
lymph nodes or her cancer is resistant to Adriamycin. New regimens
being developed are incorporating Taxol or Taxotere, with
Adriamycin.
For metastatic breast cancer other agents are also used such as:
mitomycin-C, vinblastine (Velban), and its analog, Navelbine.
Single agents (one drug alone instead of a combination) are often
given to patients who have metastatic disease for the purpose of
palliation ( relieving some symptoms even though a cure may not be
possible).

4. What is meant by adjuvant
chemotherapy?

Chemotherapy that is given in conjunction with local treatments
such as surgery is referred to as adjuvant therapy.

5. How will my chemotherapy be given to
me?

Most chemotherapy is given intravenously (in the veins). In
patients who will be receiving several months of chemotherapy, the
use of central venous access may be advisable. This is a port that
is placed under the skin surgically and is attached to a catheter
that goes directly to the central circulation of the body. You
won't need to be stuck each treatment, because the drug is
inserted into the port. It is particularly important if Adriamycin
is being administered because of its irritability to the veins.
Other agents, such as the taxanes (Taxol or Taxotere) and Navelbine
can also cause irritation to the veins. However, these indwelling
catheters have a small risk of infection and thrombosis (blood
clots).

6. Are there any oral chemotherapy drugs?

There is oral Xeloda, which is usually used in advanced cases.
There are now analogs of methotrexate, which are oral, that are
being developed.

7. What are the short term side effects of
chemotherapy?

Most commonly, chemotherapy affects the bone marrow. Cytoxan or
Cytoxan/Adriamycin, usually affect the bone marrow between days 10
and 14. Recovery occurs by day 15. In the taxanes, (Taxol or
Taxatere), bone marrow suppression usually occurs at day 8, and
then there is usually recovery by day 10 or 11. Usually,
chemotherapy is repeated every 21-24 days after patients have
recovered from all side effects (bone-marrow suppression,
mucositis, and diarrhea). CMF chemotherapy also causes bone marrow
suppression, usually in the second week. Recovery usually takes
place by day 21 or before. Adriamycin, in particular, causes hair
loss, as do the taxanes. Adriamycin can cause damage to the heart.
Congestive heart failure, irregular heart beats and other cardiac
toxicities may occur when the patient receives a cumulative dose
greater than 500 mg/m2. Therefore medical oncologists make every
effort to keep the dose as low as possible within the range of
effectiveness. Continuous (slow) infusion of Adriamycin also reduce
the cardiac toxicity. There are now cardiac-sparing medicines
available that help to protect the heart when used with Adriamycin.
There are also analogs (related compounds) being developed that are
less cardiotoxic. Stomatitis (inflammation of the mucous membranes
of the mouth), mucositis (inflammation of the lining of the mouth
and gastrointestinal tract), and diarrhea are particularly
prevalent with drugs like methotrexate, 5-fluorouracil, and
Adriamycin.

8.What are the long term effects of
chemotherapy?

Adriamycin can rarely cause long term damage to the heart- usually
congestive heart failure. As mentioned above this side effect is
dose dependent and strong efforts are now made to limit the dose
and method of administration to avoid cardiac toxicity. Taxol and
Navelbine can cause neuropathy (damage to the nerves) that involves
the hands and feet. The symptoms are usually mild but can be
severe. These effects are dose-dependent and therefore limit how
high the dose can go. Neuropathy is usually reversible, but often
persists for long periods of time.

9. Are side effects from chemotherapy
reversible?

Bone marrow suppression can be more profound after several cycles,
but is reversible. Cardiac toxicity, unfortunately, is not
reversible. Alopecia (hair loss) is reversible and the hair often
grows in curly! (chemo curls). Mucositis and diarrhea are
reversible toxicities.

10. Can chemotherapy cause secondary cancers, perhaps
many years later?

There is a very small risk of developing a secondary malignancy,
particularly leukemia, secondary to alkylating agents such as
Cytoxan. Also, very rarely, various solid tumors have been noted.
But it is important to keep in mind that the survival benefits of
chemotherapy far outweigh the small risk of secondary cancers.

11. What is a cold cap and do you recommend it to
prevent hair loss during chemotherapy?

A cold cap is a device that is placed over the patient's head
during chemotherapy to prevent hair loss. In general it's not very
effective and there has been some question about whether the
chemotherapy is being prevented from penetrating the area covered
by the cap. There is some recent data, however, to suggest that
there may be some benefit to using a cold cap to prevent Alopecia
(hair loss) when using Taxol.

12. What is a Bone Marrow Transplant?

A Bone Marrow Transplant is a procedure in which a patient's bone
marrow is replaced after being destroyed by high doses of
chemotherapy. Bone marrow is the soft, spongy material found inside
bones. IT contains stem cells, the immature cells that develop into
white and red blood cells and platelets.* Nowadays the procedure is
performed by removing the stem cells from the patient's circulating
blood. After the high dose chemotherapy is given the patient's own
stem cells are transfused back into the circulation. This is called
Peripheral blood stem cell transplantation.

13. What are the indications for a bone marrow
transplant or stem cell support?

Patients who have very aggressive disease and who are not
responsive to conventional chemotherapy are often considered for
bone marrow transplantation. These are generally patients who have
greater than 10 positive nodes or patients with metastatic disease.
A recent study has called into question the effectiveness of bone
marrow transplant verses an aggressive regimen of chemotherapy
which includes taxanes. Be sure to consult several experts before
making the decision to have a bone marrow transplant

14. How is nausea controlled during chemotherapy? What
are the commonly used anti-nausea drugs, how are they used, and how
do they differ?

Nausea and vomiting are usually well controlled by the antiemetic
medications that we have available. Common anti-nausea drugs given
IV are: Zofran (ondansetron) and Kytril (granisetron). Other
antiemetics used either orally, intravenously or by rectal
suppository are Ativan (lorazepam), Compazine (prochlorperazine),
and Reglan (metoclopramide). Marinol (dronabinol) and marijuana are
particularly helpful in young patients. The new serotonin reuptake
inhibitors, what are called H-3 blockers, have been extremely
helpful for the control of nausea and vomiting.

15. What is the HER2/neu oncogene and how does Herceptin
help?

In 25 to 30% of women with metastatic breast cancer, there is a
genetic alteration in the HER2 gene. HER2/NEU is an oncogene that
makes proteins that receives signals from growth hormones. This
protein helps tumor cells spread therefore if your tumor is HER/neu
positive it may indicate an aggressive tumor. If your tumor is
HER/neu positive, you could be eligible for a new treatment that
interfers with this gene, called Herceptin. Herceptin is one of a
biological class of drugs known as monoclonal antibodies.

There is a substantial benefit in taking Tamoxifen in a
postmenopausal female who is ER and PR positive
(Estrogen/Progesterone receptors), and for recurrent disease
(particularly soft tissue and bony metastasis). Response rates vary
but may be at least 50% in patients who are responsive to hormonal
treatments. Current recommendations for Tamoxifen usage is not to
go beyond 5 years of use. It appears that benefits are obtained at
5 years, and there may be some unwanted side effects after 5 years
of usage.

2. What are the side effects of
Tamoxifen?

Tamoxifen (Novadex) is generally well tolerated. However, hot
flashes and irritability are common. There is some concern about
Tamoxifen causing malignancies such as endometrial cancer. It is
important to have periodic endometrial biopsies while on Tamoxifen
so that endometrial cell irregularities can be diagnosed before
they become malignant. Liver cancer has also been reported rarely.
We have an extensive file on Tamoxifen at the WomanKind office. We
can give you lots of information so that you can make an informed
decision.

Its advisable to wait at least 6 months after chemotherapy is
completed before trying to become pregnant.

2. Will chemotherapy cause birth defects and should I
be tested during pregnancy?

Chemotherapy can cause birth defects in the first trimester.
Should amniocentesis or chorionic villus sampling be done?

3. How will I know if I am still fertile after
treatment?

Generally women in their 20's and 30's are more likely to
retain their fertility after chemotherapy than women in their late
30's and 40's who will often go into a chemotherapy-induced
menopause. If your period returns after treatment you are likely to
be fertile.

First order relatives are the most significant. They include your
mother, sisters and daughters. Second order relatives are your
maternal and paternal aunts and maternal and paternal grandparents.
Cousins, great-grandmothers etc don't count very much.

2. Does it matter if these relatives had breast cancer
before or after menopause?

The risks are higher for pre-menopausal cancer but first order is
still first order, whether its pre or post menopausal, and second
order is still second order whether its pre or post menopausal.

3. Should I take a blood test for genetic
predisposition?

The question is- what are you going to do with the results?
Getting this information is like opening up Pandora's box, only
worse, because first of all, a patient may be very unhappy with the
information. And unless she's going to act on the information, it
doesn't make any sense to have the test. In certain, rare
circumstances, in high-risk families, who have the BRCA-1 gene,
acting on the information can save a life. It doesn't always, but
it can. But, for most women who may be BRCA-1 positive and who
don't have a significant family history of breast cancer, we have
no idea what the data means. So, they're going to make themselves
unhappy. And then, say if one sister gets the test and finds that
she is BRCA-1 positive and tells her sister, then her sister is
going to have a number of problems. Number one: She's going to be
confronted with information she basically didn't want to know --
that there's BRCA-1 in the family. Number two: She's going to have
to decide whether she wants to get tested or not, and she may not
want to do that. Number three: She's going to have to figure out
what she's going to tell her daughters. Number four: she's going to
feel miserable because then she's going to have to confront the
fact that perhaps 50% of her daughters are carriers and are at
risk. And she, as the mother and transmitter, is going to feel
guilty for having transmitted this disease. Then, she's going to
get angry at her sister for going through this whole process to
begin with.

4. What are other problems with getting the gene
test?

If a woman is carrying the BRCA-1 gene, her insurance company may
rewrite her insurance policy to exclude her from breast cancer
treatment. Then they might search their computer file for her
relatives and exclude them as well. This could turn into a big
mess.

5. When is it ever a good idea to do genetic
testing?

When the family is clearly a high risk family -- when there are
grandmothers and maternal aunts and sisters who have breast cancer
at a young age -- bilateral breast cancer, ovarian cancer -- when
it's clear that this is likely to be a BRCA-1 family. When there
are a lot of young women at risk -- and where there have been
deaths from breast cancer. When the family kind of knows it anyway
and says, "Look, we need to know because my 28-year-old daughter
wants to know. She could have some surgical intervention or some
kind of intervention and maybe protect herself from some of the
death, which is real, in our family. And I've got four daughters
and maybe if two of them don't have this gene and they get married
and have children, they won't pass the gene on to other people.."
So, therefore, it's useful to know in that situation. And yes, we
realize that they may feel guilty that they don't have the gene and
their sisters do, but maybe we can get them to understand with
counseling that this isn't their fault -- that none of our genetic
makeup is our fault. We just inherit it. We're not responsible for
our parents -- nor are they for our genes. So in a situation of a
very high risk family it may be appropriate.

1. Is it important to maintain a low fat diet now that
I have breast cancer?

There are no current studies showing a decrease in breast
cancer recurrence rates. As for prevention of cancer, many studies
have been done and the results are contradictory. A 1996 Harvard
study of 335,000 women from four countries showed no change in
breast cancer rate in women consuming diets of 20% fat. However,
some researchers think that the crucial factor may be the diet of
adolescent girls, not grown women. Critics of the study, such as
Dean Ornish, say that the diet must be 10% fat or lower in order to
see a reduction in breast cancer. And some studies seem to indicate
that its the type of fat one consumes that's important. One study
of Greek women who ate a substantial amount of olive oil in the
diet had lower rates of breast cancer than the general
population.

2. Can being overweight or obese cause breast
cancer?

Excess pounds may predispose women to breast cancer because fat
cells produce estrogen which may stimulate breast cancer. So
although there seems to be no direct link between fat in the diet
and breast cancer, being fat can predispose to breast cancer. The
heaviest women in their 40's and 50's have twice the risk of
developing breast cancer than the leanest women of the same age.
However, there is no data concerning overweight and breast cancer
recurrences.

3. What about a vegetarian diet?

Some vegetarian diets contain dairy products and eggs which
have saturated fats similar to meat. A macrobiotic or vegan diet
(no dairy or eggs) is low in fat but we have no data on these diets
and breast cancer rates. Diet high in fruits and vegetables
prevents many types of cancers (see below). In general there are no
completed studies on preventing breast cancer recurrences with
diet. All the data is from preventing primary cancer in the general
population.

4. Can Tofu or other soy products prevent cancer or
prevent recurrences?

Soy products may be protective against breast cancer. Protease
inhibitors present in soy products suppress the production of
enzymes in cancer cells which may slow tumor growth. Isoflavones
block the entry of estrogen into cells, which may reduce the risk
of breast cancer. We have no information about soy products
preventing recurrence and some women are concerned that the
phytoestrogen (plant estrogen) in soy may stimulate tumor
growth.

5. What about anti-oxidants?

A diet high in fruits and vegetables, which contain high levels
of antioxidants, have been shown to prevent many types of cancers.
However, there are no completed studies proving lower breast cancer
recurrence rates.

6. How much alcohol is it safe to drink now that I have
breast cancer or DCIS?

Studies on alcohol and breast cancer are also contradictory and
we don't know of any studies done on women who already have breast
cancer. It appears that drinking alcohol under the age of 30 may
increase breast cancer rate. In the general population of women,
drinking more than nine drinks per week, seems to have a 1.6
increase in the rate of breast cancer (1 is the norm).

7. Will exercise help? What type?

Aerobic exercise has been shown to reduce breast cancer rates
in women. It is not know if this is because of the reduction in
body fat. Our body fat contains high levels of estrogen, which may
stimulate cancer cells. Mild to moderate exercise may strengthen
the immune system. As with diet, there are no studies yet
demonstrating a reduction in recurrence rates in women who already
have breast cancer. Of course exercise is healthy for so many
reasons.